Cx vs Radiotx en KC

Comparison of Surgery vs Radiation Therapy for Non-Melanoma Skin Cancers

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Haley O'Meara, PA-C 

January 30, 2026

Non-melanoma skin cancer (NMSC), also referred to as keratinocyte carcinoma, primarily consists of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC).¹ Combined, BCC and SCC make up nearly 95% of skin malignancies and are the most commonly diagnosed cancers in humans.^2,3 The primary risk factor for developing NMSC is ultraviolet radiation from the sun or artificial sources, which cause DNA alterations, as well as production of reactive oxygen species and a reduction in cell-mediated immune responses, leading to cellular damage.^4-7

The prognosis for NMSC is favorable when it is discovered early, although this varies by subtype based on the subtype's behavior and potential to metastasize.²  BCC is less prone to metastasize but can be locally aggressive and invade nearby structures, whereas SCC has a higher tendency to be aggressive and spread to regional lymph nodes.⁸ Untreated NMSC lesions can lead to functional impairment, pain, changes in appearance, and even death, making timely treatment important.

Surgery is the traditionally preferred treatment for most cases of NMSC, with Mohs micrographic surgery (MMS) being the gold standard for NMSC lesions that are high risk, recurrent, or located in anatomically sensitive areas.^1,9 A non-surgical alternative known as image-guided superficial radiation therapy (IG-SRT) has demonstrated remarkable efficacy in the treatment of NMSC lesions and is emerging as a prominent treatment modality.^10,11

Mohs Surgery: The Gold Standard

MMS, developed in the 1930s by Dr Frederic Mohs, serves as the gold standard approach for treating select NMSC lesions.^8,9  As noted, MMS is the standard of care for NMSC lesions categorized as high risk, recurrent, or located in anatomically sensitive areas.^1,9 The MMS technique focuses on precision and tissue preservation.^8,12 The development of this procedure marked a significant advancement in the management of NMSC, as it preserves both appearance and function compared with the standard surgical technique.

Efficacy

MMS has proven to be highly efficacious based on extensive research. A comprehensive 5-year study on the outcomes of MMS showed a 99% cure rate for the treatment of primary BCCs and a 92% to 99% cure rate for the treatment of SCCs.¹³ MMS also has demonstrated a higher cure rate than standard excision for the management of high-risk NMSC lesions.⁸ The thorough approach taken during MMS reduces the likelihood of incomplete removal of the skin cancer roots.¹²

Safety and Cosmetic Outcomes

Overall, patients tolerate MMS well and express high satisfaction regarding cosmetic results. The minimally invasive technique used in MMS focuses on tissue preservation. The procedure is performed under local anesthesia and begins with the removal of a thin, 1- to 2-mm margin of tissue.^8,12,13 The specimen is frozen, sectioned into thin slices, stained, and placed onto slides to evaluate for any remaining cancer cells under a microscope.^8,13 If positive margins remain, the patient is prepped for a second stage and the procedure is repeated until margins are clear of residual cancer cells.¹³ Once complete clearance of margins is achieved, the Mohs surgeon typically closes the surgical site the same day with a complex linear closure, skin flap, or graft depending on the skin defect.¹² After closure, the patient typically is given aftercare instructions and a follow up visit is scheduled for suture removal, if necessary.  In contrast, a standard excision involves the removal of 4- to 6-mm margins down to the mid-subcutaneous adipose tissue.^1,8

Read More: Squamous Cell Carcinoma Stages (in situ, 1-4, metastatic)

It is also important that patients receive clear instructions on wound care to reduce the risk for complications and promote optimal healing. Although most patients experience pleasing cosmetic results with MMS, some can have distress related to scarring, bandaging, or sutures postprocedure.¹⁴ Complications that arise after MMS include bleeding, infection, nerve damage, and reopening of the wound.¹¹ To reduce the risk for complications, some patients are prescribed prophylactic antibiotics or asked to temporarily discontinue their anticoagulant medication for a period of time before the procedure.¹²

Patients with a pacemaker or implantable cardioverter defibrillator may need to turn off their cardiac device, if possible, or have the Mohs surgeon use a disposable electrocautery device to eliminate concerns related to the use of standard electrocautery.¹²

Patient Eligibility 

Determining patient eligibility for MMS is a crucial step in ensuring procedure appropriateness and success. The American Academy of Dermatology (AAD) recommends MMS for all high-risk NMSCs.⁸ High-risk NMSCs may include tumors that are larger than 2 cm, invasive histologic subtypes, sites with high recurrence rates, or sites in anatomical locations where tissue preservation is required.^1,13 MMS is not recommended for patients with medical comorbidities that reduce overall general health or for patients who have abnormal bleeding tendencies.¹⁰

IG-SRT: A Non-Invasive Alternative

IG-SRT was approved by the Food and Drug Administration in 2015. IG-SRT was developed to enhance the effectiveness of superficial radiation therapy (SRT),¹¹ which previously was used by dermatologists to treat NMSC but was replaced by MMS because of the higher cure rates seen with the surgery.¹⁵ IG-SRT uses a high-resolution dermal ultrasound and Doppler features to visualize the depth, width, and overall structure of skin tumors before, during, and after treatment.¹⁵IG-SRT is a precise procedure administered by a board-certified radiation therapist.^11,16

"Studies of IG-SRT report a greater than 99% local cure rate for early-stage NMSC lesions. MMS has a 5-year local control rate of 99% for BCC lesions and 92% to 99% for SCC lesions."

The technique begins with ultrasound visualization of the exact dimensions of the skin tumor.^3,11 Because the ultrasound imaging allows the tumor to be visualized prior to, during, and after treatment, the provider can adjust radiation dosages, if needed, and confirm lesion response to treatment.¹⁵ A 22-MHz high-resolution dermal ultrasound is used, which allows for visualization of skin depths up to 6 mm.¹⁰ The energies of penetration range from 50 to 100 kV and are calculated by using the tumor dimensions, as well as percentage depth dose tables provided by the ultrasound device manufacturer.^10,16 Treatment typically lasts 15 minutes and occurs 3 to 5 times per week for 4 to 7 weeks.¹¹

Efficacy

The use of image-guided ultrasound has made IG-SRT a treatment that is superior to SRT and that demonstrates cure rates that are comparable to those of MMS.¹⁵ In a recent study evaluating IG-SRT for histologically proven NMSC lesions, 2897 out of 2917 lesions showed no signs of residual tumor after treatment, resulting in a 99.3% local control rate.¹⁵ Another study examined 1899 NMSC lesions undergoing IG-SRT for 7.5 weeks showed a local control rate of 99.7%.¹⁶ Data from these studies showing the high local cute rate of over 99%, which supports IG-SRT as a highly effective treatment modality for managing NMSCs.¹⁶

Safety and Cosmetic Outcomes

IG-SRT is a well-tolerated, safe procedure that yields favorable cosmetic results.¹⁰ This procedure uses precise, low-penetration kilovoltage (kV) to target superficial skin lesions, avoiding damage to healthy tissue or deeper structures.¹⁶ IG-SRT's noninvasive technique helps preserve tissue in cosmetically sensitive areas, resulting in exceptional cosmetic outcomes.¹⁵

The procedure has demonstrated a mild side effect profile. Most side effects typically are self-resolving and last for 2 to 6 weeks following treatment.^11,16 Common side effects include hyperpigmentation, desquamation, erythema, and dryness, which can be controlled with over-the-counter cream or ointment.^10,11,16

Patient Eligibility

IG-SRT is an attractive treatment option for patients with superficial NMSCs, as well as patients who refuse surgery or are not surgical candidates. This procedure is recommended by the AAD for patients with early-stage NMSC who do not qualify for surgery.¹⁶ It also can be beneficial for patients with NMSC lesions located in cosmetically sensitive areas.¹⁵ However, not all patients are candidates for IG-SRT because of various contraindications. These include lesions that invade bone or muscle or have a depth greater than 6 mm, a past history of radiation therapy to the same site, connective tissue disease, rheumatologic disease, or current use of chemotherapy agents that increase sensitivity to radiation.¹⁵ Both patient eligibility and contraindications should be reviewed before offering IG-SRT as an option.

Comparative Analysis

MMS and IG-SRT both demonstrate high local cure rates in the management of NMSC, with IG-SRT showing a greater than 99% local cure rate for early-stage NMSC lesions,^15,16 and MMS demonstrating a 5-year local control rate of 99% for BCC lesions and 92% to 99% for SCC lesions.¹⁰ As a noninvasive approach, IG-SRT is a valuable treatment modality, especially when surgery is not preferred or is contraindicated.  MMS has proven to be highly effective in this setting and currently is the gold standard treatment for most NMSC lesions. Although both procedures offer exceptional local cure rates, factors such as patient preference, patient eligibility for the procedure, and lesion characteristics should be considered when choosing a treatment method to ensure safe, favorable outcomes.

MMS with IG-SRT each have advantages and disadvantages related to safety and cosmetic outcomes. MMS is notable for preserving tissue and taking minimal margins.¹ Since this is a surgical procedure, there is a risk for scarring, bleeding, and infection.¹¹ Special consideration must be given to patients with cardiac devices, as well as those who require prophylactic antibiotics or are on certain medications, such as anticoagulants.¹² However, the majority of complications can be taken care of in-office, and patients typically are happy with the cosmetic results following surgery.^12,14 

IG-SRT has favorable results without the need for surgical intervention. It avoids complications such as scarring, infection, and bleeding that can be seen with MMS.^1,15 This is especially important in patients who have skin that is prone to scarring or keloids.¹⁶ IG-SRT also offers advantages over MMS by preserving tissue in lesions in cosmetically challenging areas, such as the scalp, where closure is difficult, or lower legs, which heal more slowly because of poor vascularization, posing a higher risk for infection.¹⁵ It is also important to note that IG-SRT does not require local anesthesia, discontinuation of medications, or prophylactic antibiotics.¹¹

MMS is typically completed during one office visit and takes about 2 to 4 hours depending on the number of stages needed to reach tumor clearance.¹¹ A 1-day procedure is especially important to consider for patients who live far from the office, have trouble commuting to it, or have limited time off work. 

Unlike MMS, IG-SRT has the capability to treat up to 4 lesions at once.^11,16 This provides a significant advantage for patients who have multiple NMSC lesions that need to be treated. IG-SRT also has a shorter office visit time of about 15 minutes but requires 3 to 5 treatments a week over the course of 4 to 7 weeks.¹¹ While the shorter office visits sound appealing, the treatment course requires commitment from patients for multiple visits to ensure that treatment is effective.

Although MMS is the gold standard for NMSC treatment, surgery may be contraindicated in patients with certain medical conditions, such as chronic edema, bleeding abnormalities, or cardiac conditions, and IG-SRT could be used as an alternative in such cases.^11,16 In addition, a patient may decline MMS due to personal preference and opt to receive IG-SRT.

IG-SRT does have limitations and cannot be used in certain scenarios. For example, lesions that are larger than 2 cm or have previously received radiation therapy are contraindicated for IG-SRT; in such cases, MMS may be a better option.¹⁵Eligibility and contraindications for MMS and IG-SRT require careful consideration on a case-by-case basis before choosing an appropriate procedure for each patient. 

Conclusion

When comparing MMS to IG-SRT, preservation of function and cosmesis, along with patient preference and tumor characteristics should be considered by both the patient and provider. Both procedures are considered safe and well-tolerated, with high patient satisfaction rates. When formulating a treatment plan for a patient with NMSC, the efficacy, safety, and cosmetic outcomes, procedure details, and patient eligibility for each procedure should be considered to ensure optimal outcomes.

This article originally appeared on Clinical Advisor

References:

1. Firnhaber JM. Basal cell and cutaneous squamous cell carcinomas: diagnosis and treatment. Am Fam Physician. 2020;102(6):339-346.
2. Didona D, Paolino G, Bottoni U, Cantisani C. Non melanoma skin cancer pathogenesis overview. Biomedicines. 2018;6(1):6. doi:10.3390/biomedicines6010006
3. Catalano O, Roldán FA, Varelli C, Bard R, Corvino A, Wortsman X. Skin cancer: findings and role of high-resolution ultrasoundJ Ultrasound. 2019;22(4):423-431. doi:10.1007/s40477-019-00379-0

4. Paulitschke V, Gerner C, Hofstätter E, et al. Proteome profiling of keratinocytes transforming to malignancy. 2015;36(4):564-576. doi: 10.1002/elps.201400309
5. Ouhtit A, Muller HK, Gorny A, Ananthaswamy HN. UVB-induced experimental carcinogenesis: dysregulation of apoptosis and p53 signalling pathway. Redox Rep.2000;5(2-3):128-129. doi: 10.1179/135100000101535447
6. López-Camarillo C, Ocampo EA, Casamichana ML, Pérez-Plasencia C, Álvarez-Sánchez E, Marchat LA. Protein kinases and transcription factors activation in response to UV-radiation of skin: implications for carcinogenesis. Int J Mol Sci.2012;13(1):142-172. doi: 10.3390/ijms13010142
7. Rittié L, Fisher GJ. UV-light-induced signal cascades and skin aging. Ageing Res Rev.2002;1(4):705-720. doi: 10.1016/s1568-1637(02)00024-7
8. Badash I, Shauly O, Lui CG, Gould DJ, Patel KM. Nonmelanoma facial skin cancer: a review of diagnostic strategies, surgical treatment, and reconstructive techniques. Clin Med Insights Ear Nose Throat. 2019;12:1179550619865278. doi:10.1177/1179550619865278

9. Dika E, Scarfì F, Ferracin M, et al. Basal cell carcinoma: a comprehensive review. Int J Mol Sci. 2020;21(15):5572. Published 2020;21(15):5572. doi:10.3390/ijms21155572
10. Yu L, Oh C, Shea CR. The treatment of non-melanoma skin cancer with image-guided superficial radiation therapy: an analysis of 2917 invasive and in situ keratinocytic carcinoma lesions. Oncol Ther. 2021;9(1):153-166. doi:10.1007/s40487-021-00138-4

11. McClure EM, Sedor G, Jin Y, Kattan MW. Image-guided superficial radiation therapy has superior 2-year recurrence probability to Mohs micrographic surgery. Clin Transl Radiat Oncol. 2023;43:100678. doi:10.1016/j.ctro.2023.100678
12. Bittner GC, Cerci FB, Kubo EM, Tolkachjov SN. Mohs micrographic surgery: a review of indications, technique, outcomes, and considerations. An Bras Dermatol. 2021;96(3):263-277. doi:10.1016/j.abd.2020.10.004

13. Chen ELA, Srivastava D, Nijhawan RI. Mohs micrographic surgery: development, technique, and applications in cutaneous malignancies. Semin Plast Surg. 2018;32(2):60-68. doi:10.1055/s-0038-1642057

14. Vaidya TS, Mori S, Dusza SW, Rossi AM, Nehal KS, Lee EH. Appearance-related psychosocial distress following facial skin cancer surgery using the FACE-Q Skin Cancer. Arch Dermatol Res. 2019;311(9):691-696. doi:10.1007/s00403-019-01957-2
15. Yu L, Moloney M, Zheng S, Rogers J. High resolution dermal ultrasound (US) combined with superficial radiation therapy (SRT) versus non-image guided SRT or external beam radiotherapy (XRT) in early-stage epithelial cancer: a comparison of studies. BMC Cancer. 2023;23(1):98. doi:10.1186/s12885-023-10577-z
16. Tran A, Moloney M, Kaczmarski P, et al. Analysis of image-guided superficial radiation therapy (IGSRT) on the treatment of early-stage non-melanoma skin cancer (NMSC) in the outpatient dermatology setting. J Cancer Res Clin Oncol. 2023;149(9):6283-6291. doi:10.1007/s00432-023-04597-2

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Skin Care Physicians of Costa Rica

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Tattoos and Melanoma Risk

Tattoos and Melanoma: A Surprising Signal from a Large Population Study by Alexander Stratigos, MD

INTRODUCTION Tattoos are increasingly common worldwide, yet their long-term health implications—particularly in relation to skin cancer—remain incompletely understood. While tattoo inks may contain potentially carcinogenic substances and induce chronic inflammatory responses in the skin, epidemiological evidence linking tattooing to melanoma has been scarce and conflicting. A new large populationbased case–control study offers timely and provocative data, challenging prevailing assumptions and opening new avenues for research. MAIN POINTS Study design:  Population-based case–control study including 1,167 melanoma cases (in situ and invasive) and 5,835 matched controls from Utah, the US state with the highest melanoma incidence Results: Overall tattoo exposure: Ever having a ta#oo was not associated with melanoma risk overall (OR 0.92, 95% CI 0.74–1.13), nor with invasive melanoma (OR 0.81, 95% CI 0.60–1.09). Dose-related findings: Individuals with ≥4 tattoo sessions had a 56% lower risk of melanoma (OR 0.44, 95% CI 0.27–0.67) and a similar reduc7on for invasive melanoma (OR 0.43,95% CI 0.24–0.80). Those with ≥3 large tattoos showed an even stronger inverse association (overall melanoma OR 0.26, 95% CI 0.10–0.54; invasive melanoma OR 0.23, 95% CI 0.07–0.75). Receiving the first tattoo before age 20 was associated with a reduced risk of invasive melanoma (OR 0.48, 95% CI 0.29–0.82). Sex-specific differences: Among men, ≥4 tattoo sessions were associated with a marked reduction in melanoma risk (overall OR 0.25, 95% CI 0.09–0.53; invasive OR 0.15, 95% CI 0.04–0.62). Among women, associations were weaker and mostly non-significant (≥4sessions: overall OR 0.64, 95% CI 0.36–1.07). Low-level exposure signal: A single tattoo session was associated with an increased risk of in situ melanoma, particularly in women (overall OR 1.53, 95% CI 1.16–2.00; women OR 1.90, 95% CI 1.30–2.74), suggesting possible detection or behavioral bias. No evidence of colocalization: Fewer than 7% of tattooed melanoma cases reported a melanoma arising within 6 inches of a tattoo, arguing against a direct local carcinogenic effect.

Comment In this large population-based case–control study, tattooing was not associated with an increased risk of melanoma. Unexpectedly, higher levels of tattoo exposure (multiple tttoo sessions or several large tattoos) were associated with a lower risk of melanoma, particularly invasive disease and more prominently among men. While these findings challenge long-standing concerns about tattoo inks and carcinogenicity, the authors emphasize that unmeasured confounding and behavioral factors may partly explain the results, and further research is needed.

McCarty RD, Trabert B, Collin LJ, et al. Ta7ooing and risk of melanoma: a populaAon-based case-control study in Utah. J Natl Cancer Inst. 2025 Dec 1;117(12):2495-2504. doi: 10.1093/jnci/djaf235. PMID: 40839395

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¿Psoriasis pediatrica: cuales tratamientos son mejores?

Superior Drug Survival Identified Among Systemic Therapies

for Pediatric PsO

Lisa Kuhns, PhD |

December 5, 2025

Acitretin and methotrexate show comparable 2-year drug survival, and both

outperform cyclosporine in pediatric patients with severe psoriasis, according to

results of a study published in the Journal of the European Academy of

Dermatology & Venereology.

Researchers conducted an international retrospective study at 30 centers located in

France, Italy, the United Kingdom, Canada, and Portugal. Patients eligible for

inclusion were under 18 years old at initiation of systemic treatment for the first

time; received acitretin, methotrexate, or cyclosporine as a single-agent therapy; had

taken the medication for at least 1 day; and attended at least 1 follow-up consultation

following the initial prescription.

Of the 506 pediatric patients with severe psoriasis included, 683 systemic treatment

courses were analyzed: 316 with acitretin, 245 with methotrexate, and 122 with

cyclosporine. The mean age at treatment initiation was 10.3 years. Plaque psoriasis

was the most common subtype (61.6%), followed by palmoplantar (14.1%) and guttate

(13.1%). Nail involvement (28.3%) and psoriatic arthritis (3.6%) were relatively

uncommon. The choice of initial systemic therapy varied significantly by country,

age, sex, and phenotype. Acitretin was favored in younger patients, those with

palmoplantar disease (odds ratio [OR], 3.88, P =.003), and those without psoriatic

arthritis (OR, 0.15; P =.005). Methotrexate was used more frequently in women, and

cyclosporine use was concentrated in Italian centers (OR, 5.50, P <.0001).

https://www.dermatologyadvisor.com/news/superior-drug-survi03a4297c649084&hmsubid=&nid=2049200711&elqtrack=True 18/12/25, 3:41 AM

Page 1 of 3Median drug survival was significantly longer for acitretin (10.79 months) and

methotrexate (10.92 months) compared with cyclosporine (3.95 months; P <.0001).

Acitretin had higher persistence when used as a first-line therapy vs as a

subsequent therapy (11.3 vs 5.5 months; P <.0001), but this association was not

observed for methotrexate or cyclosporine. Effectiveness at 3 months was

comparable across drugs for both Physician's Global Assessment scores of 0/1 (41.4%

to 47.3%; P =.77) and Psoriasis Area and Severity Index score of 75 (30.7% to 34.8%; P

=.89).

"

These findings may aid in developing algorithms to

formulate recommendations for systemic treatments in

"

managing severe psoriasis in pediatric patients.

Discontinuations were mainly due to inefficacy with cyclosporine (43.0%) and loss of

effectiveness with methotrexate (31.8%) and acitretin (27.2%). Adverse events led to

discontinuation in 13.8% to 23.1% of patients. The most common adverse events were

cheilitis and xerosis/pruritus with acitretin; gastrointestinal symptoms, fatigue, and

transaminase elevations with methotrexate; and hypertrichosis with cyclosporine.

Only 1 serious adverse event, transaminase elevation with methotrexate, was

reported.

The study limitations include participation by only 1 center each in Canada and

Portugal as well as missing data on some efficacy measures.

The researchers concluded, "These findings may aid in developing algorithms to

formulate recommendations for systemic treatments in managing severe psoriasis

in pediatric patients."

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical,

and/or device companies. Please see the original reference for a full list of authors'

disclosures.

References:

https://www.dermatologyadvisor.com/news/superior-drug-survi03a4297c649084&hmsubid=&nid=2049200711&elqtrack=True 18/12/25, 3:41 AM

Page 2 of 3Miao Y, Beauchet A, Piram M, et al. Drug survival of systemic treatments for severe

paediatric psoriasis: an international retrospective study. J Eur Acad Dermatol

Venereol . Published online October 17, 2025. doi:10.1111/jdv.70108

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Skin Care Physicians of Costa Rica

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Secretomas vs exosomas

La diferencia clave reside en el alcance: el secretoma es la combinación completa de moléculas de señalización (factores de crecimiento, citocinas, ARN) que libera una célula, mientras que los exosomas son un tipo específico de vesículas diminutas, unidas a la membrana, dentro del secretoma. Actúan como nanotransportadores específicos para cargas específicas como proteínas, lípidos y ARN, entregando instrucciones precisas entre células para la regeneración y la comunicación. Piense en el secretoma como la transmisión de radio completa, y en los exosomas como los mensajes de texto personalizados.


Secretoma

Qué es: El conjunto completo de todas las sustancias secretadas por una célula o tejido.
Contenido: Incluye exosomas, microvesículas, factores de crecimiento de libre flotación (como las citocinas), péptidos y otras moléculas solubles.

Función: Proporciona un amplio espectro de señales, promoviendo la comunicación celular general, la regulación de la inflamación y la reparación tisular.
Analogía: Un gran camión de correos que entrega paquetes y cartas a un área general.

Exosomas

Qué es: Un tipo específico de vesícula extracelular (VE), de tamaño nanométrico (30-150 nm). Contenido: Proteínas, lípidos, ARNm y microARN encapsulados, protegidos por una membrana lipídica.

Función: Actúan como "mensajeros" dirigidos, entregando instrucciones genéticas y proteicas precisas directamente a las células receptoras para obtener respuestas específicas (p. ej., desencadenar la producción de colágeno).

Analogía: Un mensajero en bicicleta con una carta sellada y específica para una dirección específica.

Puntos clave de la terapia:
La terapia con secretomas ofrece un tratamiento amplio e integral para la regeneración general.

La terapia con exosomas proporciona una administración altamente dirigida y precisa de señales regenerativas, ideal para el rejuvenecimiento celular específico.



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Skin Care Physicians of Costa Rica

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Menopause and skin

Dermatologists discuss dermatologic changes before and during menopause and the dermatoses that may occur.

Feature

By Allison Evans, Assistant Managing Editor, December 1, 2025

Menopausal transitions can be stressful. While rapidly declining estrogen levels can wreak havoc internally, many of these changes involve the skin, hair, and vulvar region — all of which can severely impact self-esteem, relationships, and everyday functioning.

Menopause, a time marked by not having menstrual periods for 12 months in a row, typically happens between the ages of 45 to 55. Perimenopause starts about two to eight years before menopause. During this time, women may notice changes, including drier skin, decreased skin laxity, hair loss, acne, and vulvovaginal dryness, said Melissa Mauskar, MD, FAAD, current member of the board of directors for the Women's Dermatologic Society, associate professor in the departments of dermatology and obstetrics and gynecology in Dallas, and director of the Vulvar Health Program at UT Southwestern.

"This transition from perimenopause to menopause can affect every single organ in your body, and since skin is the largest organ, we see those effects in so many places that dermatologists interface with on a daily basis," she added. 

Skin and nail changes 

During menopause, skin quickly loses collagen, which can lead to skin thinning, wrinkling, and sagging. Studies show that women's skin loses about 30% of its collagen during the first five years after menopause. After that, the decline is more gradual with women losing about 2% of their collagen every year for the next 20 years. 

As hormone levels plummet, these skin changes can also cause some women to develop teenage-like acne. "Acne treatment was designed for the teenage or early adult patient," noted Miriam Pomeranz, MD, FAAD, associate professor at NYU Grossman School of Medicine and chief of dermatology service at Bellevue Hospital. 

"When you're treating acne for perimenopausal or post-menopausal patients, you need to balance the irritation of topical treatments with the underlying dryness of the skin. You can advise patients to use a moisturizer first and then apply the topical acne treatment as well as using water-based cosmetics," she recommended.

"After menopause, estrogen levels rapidly decrease, while testosterone diminishes gradually, causing a relative androgen excess. You may see female pattern hair loss, acne, and hirsutism in these patients," Dr. Mauskar said. "That's when spironolactone becomes a go-to treatment to help with that excess androgen."

Dr. Mauskar noted that topical retinoids are tried and true for hormonal acne during perimenopause. "I try to get patients to use topical retinoids not only for their acne but also to help with fine lines, wrinkles, and dyspigmentation."

"After menopause, estrogen levels rapidly decrease, while testosterone diminishes gradually, causing a relative androgen excess. You may see female pattern hair loss, acne, and hirsutism in these patients."

On the other hand, some women may notice that their persistent acne disappears, said Nanette Silverberg, MD, FAAD, editor-in-chief of the International Journal of Women's Dermatology and chief of pediatric dermatology for Mount Sinai Health Systems. "Unfortunately, some women may then get rosacea, which is significantly triggered by hot flashes," she added.

Dermatologists agree that sun protection is one of the best, and simplest, ways to reduce skin changes from menopause. Sunscreen can reduce the compounding effect of light on collagen loss, reduce and prevent wrinkles, and prevent further thinning of the skin. Sunscreen can also help treat dark spots that can develop or darken during menopause. Dr. Mauskar emphasized that a lot of patients in that perimenopausal transition can still prevent some of the later stages of skin changes by using sunscreen.

"While skin and hair changes may be the most prominent symptoms during perimenopause and post-menopause, some patients may also notice nail changes," said Audrey Fotouhi, MD, FAAD, assistant professor of medicine at the University of Chicago. "Patients may experience longitudinal ridging or onychorrhexis, which are often related to xerosis. I tell my patients that their nails are going to get wrinkled like their skin." Patients may also experience nail changes from lichen planus, which is more common during the menopause process, she added.

Caring for your skin during menopause

---

Share these tips with your patients about how to address skin changes during menopause, including age spots, facial hair, and hair loss. 

Flaring of inflammatory skin conditions

During perimenopause, some patients experience flares of atopic activity from vascular flaring. "Patients with atopic dermatitis or asteatotic dermatitis may experience extreme itching during hot flashes," Dr. Silverberg pointed out. 

"Sometimes people have had discontinuous atopic dermatitis throughout adulthood and may experience flaring during that perimenopausal period," she added. Other inflammatory conditions, like psoriasis, can flare during perimenopause. With hormonal fluctuations linked to inflammatory disease activity, systemic estrogen and/or progesterone may potentially be a useful treatment.

"As women age, there is a shift in becoming more Th2 dominant in terms of an immune response, which drives a lot of the different forms of skin involvement that we see in perimenopausal and post-menopausal women," said Jenny Murase, MD, FAAD, former secretary of the Women's Dermatologic Society, past co-editor in chief of the International Journal of Women's Dermatology, and associate clinical professor at the University of California, San Francisco.

"Something is shifting in the immune system to become more allergic dominant, and that can present as itching or red bumps. Eczema can become more prominent because we don't make as much oil on the surface of the skin as we age," Dr. Murase said. Because of this immune shift, she is more hesitant to use immunosuppressive agents in older patients.

"It's important to continue gathering data as the relationship between perimenopausal and menopausal changes and flaring of skin conditions is not well understood."

The impact of menopause on hidradenitis suppurativa (HS) is unclear, with contradictory and inconsistent evidence. While menopause had previously been thought to be accompanied by a decline in HS disease severity, a 2020 study found that after menopause, participants reported either worsening (40%) or no change (44%) in HS symptoms. The authors speculated that this could be because patients were older at the time of menopause and had a longer time to develop increased numbers of lesions in more anatomic regions, so that the overall disease burden was thought to be higher with menopause (doi: 10.1016/j.ijwd.2020.07.002). Additionally, there is some evidence to suggest that hormone replacement therapy has a risk of worsening disease activity.

"It's important to continue gathering data as the relationship between perimenopausal and menopausal changes and flaring of skin conditions is not well understood," said Dr. Silverberg. "It's hard to say why these conditions flare. Is it because people are gaining weight, which contributes to inflammation? Is it the tendency toward metabolic syndrome that comes with age?"

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What to tell your patients about collagen supplements

Hair

Women in perimenopause and/or menopause may have an increased risk of a genetic predisposition for hair thinning — the most common one being androgenetic alopecia, said Kristen Lo Sicco, MD, FAAD, associate professor at the Ronald O. Perelman Department of Dermatology at NYU Grossman School of Medicine. The progressive hair thinning can occur at the temples and at the top of the scalp manifesting as a widened part, she said.

"During menopause, the anagen phase of the hair cycle shortens so many women will note that their hair doesn't grow as long as it used to. This is all part of androgenetic alopecia process," Dr. Lo Sicco added. "There can be textural changes as well. Some women may experience drier, more brittle hair."

Dr. Lo Sicco emphasized the importance of making sure patients are up to date on their annual physical to ensure there are no other contributing factors, such as thyroid issues or nutritional deficiencies.

For some of Dr. Mauskar's older postmenopausal patients with hair loss, she rarely prescribes topical minoxidil. "Many of these patients do not wash their hair as often and may go to the salon once a week to get their hair styled. They tend to be very resistant to topical minoxidil, and so I will often reach for an oral pill, like minoxidil, and then educate them about the fact that it may cause increased hair everywhere."

Treatments like low-dose oral minoxidil have become incredibly popular to treat both male and female pattern thinning because it's nonhormonal, and some patients are concerned about the potential for depressed mood or sexual side effects with anti-androgens, Dr. Lo Sicco said.

Finasteride is often used off-label to treat hair loss in post-menopausal women, and it's used at higher doses in women than men, she noted. "The FDA-approved dose for men is 1 mg, whereas we start most women at 2.5 mg."

Shedding light on female pattern hair loss

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Hair experts discuss the efficacy and safety of off-label treatments for female pattern hair loss. 

Vulvar dermatoses

Menopause brings with it an increased risk of certain vulvar conditions, including genitourinary syndrome of menopause and lichen sclerosus. "These conditions often go undiagnosed for years because women don't feel comfortable discussing these symptoms, and they may not be seeing their gynecologist as regularly post-menopause," Dr. Silverberg noted.

GSM

Genitourinary syndrome of menopause (GSM, previously known as vulvovaginal atrophy) affects up to 84% of post-menopausal women. Diminished estrogen levels after menopause lead to vulvovaginal thinning, decreased secretions, pale mucosa, loss of rugae, and occasional erythema. Common symptoms include dryness, burning, itching, pain, dyspareunia, and recurrent urinary tract infections. If untreated, GSM typically worsens over time and can significantly impact quality of life (doi: 10.1016/j.jaad.2025.04.052).

Low-dose topical vaginal estrogen is the cornerstone of GSM treatment, Dr. Pomeranz said. It normalizes vaginal pH, restores microflora, thickens the epithelium, enhances secretions, and provides urinary benefits. There is strong safety data showing limited systemic absorption and no increased risk of breast or endometrial cancer, heart disease, stroke, or venous thromboembolism with this therapy (doi: 10.1016/j.jaad.2025.04.052). 

Lichen sclerosus

Lichen sclerosus is a chronic inflammatory condition that can present in children and during reproductive years. However, it commonly occurs during menopause, said Dr. Pomeranz. Lichen sclerosus is very important to treat, she stressed. 

"It can cause symptoms like irritation or itching, particularly during menopause, and dyspareunia. Even without causing symptoms, it can cause scarring, which then can interfere most commonly with sex, but possibly even with urination. Other signs to be aware of include white, raised bumps, textural changes, and thinning of the skin," she added.

Without treatment, lichen sclerosus can progress to malignancy, Dr. Pomeranz explained. "There's some evidence suggesting that women who treat it don't have a higher rate of malignancy than the general population, whereas women who don't have their lichen sclerosus treated experience higher rates of malignancy — squamous cell carcinoma of the vulva in particular."

"As dermatologists, we're very adept at recognizing and treating lichen sclerosus, and the first-line treatment is still potent topical steroids. It's a fairly simple treatment that dermatologists should be comfortable prescribing," she added. 

"Our older post-menopausal patients are not getting regular pap smears anymore, so they're not getting regular gynecologic exams. We need to be the ones to look."

Dr. Pomeranz stressed that dermatologists need to recognize that topical steroids are safe to use on the modified mucous membrane of the vulva. "A topical steroid, which might normally thin skin and cause issues, tends to not cause problems if kept in those areas. If it gets onto hair-bearing skin or skin folds, then you can run into issues like striae and thinning of the skin."

Making vulvar dermatoses even more complicated to diagnose, menopause can cause changes to the structure of the vulva as well. "Lichen sclerosus often scars the labia minora by fusing them with the labia majora, but sometimes by allowing them to resorb. Menopause also sometimes allows for the resorption of the labia minora. Just because the labia minora are getting smaller, or even absent, does not by definition mean someone has lichen sclerosus," she said.

Genitourinary syndrome of menopause can cause patients to experience symptoms similar to those of lichen sclerosus or even lichen planus, including persistent dryness, pruritus, or dyspareunia, Dr. Pomeranz stated. 

"It is nearly impossible to tell whether someone has treated or partially treated lichen sclerosus or has genitourinary syndrome of menopause and is experiencing architectural changes associated with menopause," Dr. Pomeranz said. 

Examining the vulvar region is critical to ensuring there are no skin cancers, which are more common in post-menopausal women, Dr. Pomeranz noted. Vulvar squamous cell carcinoma is the most common vulvar cancer, but vulvar melanoma is deadly. "The prognosis is often poor due to late diagnosis and its high potential to metastasize."

Topical estrogen, hormone replacement therapy

While Dr. Pomeranz does not prescribe systemic estrogens, she will prescribe topical estrogen. Her menopausal patients on topical estrogen are followed by a gynecologist because, "it's possible that topical estrogen will induce spotting — and that has to be fully evaluated 100% of the time."

Many dermatologists have received little to no training in using vaginal estrogen, making it underutilized in practice. "It can make such a big difference in relieving patients' symptoms," Dr. Mauskar added. 

"If your patient is experiencing vulvar itch and they have a normal vulva, topical estrogen is a great place to start," said Dr. Fotouhi. "It is so safe, even in patients with a history of cancer. There's a lot of recent data published on its safety, including its low systemic absorption."

A 2002 Women's Health Initiative study linked systemic hormone replacement therapy (HRT) to increased cardiovascular and cancer risk, fueling longstanding misconceptions about the treatment, and an FDA boxed warning for topical vaginal estrogen. However, in November 2025, the FDA said it will remove the boxed warning from more than 20 hormone-based drugs, like estrogen and progestin, approved to ease hot flashes, night sweats, and other menopause symptoms. The FDA, led by Commissioner Marty Makary, MD, MPH, published a commentary in JAMA (doi: 10.1001/jama.2025.22259).

While most dermatologists would not find themselves prescribing HRT, it is important to be aware of patients who are using it. "In theory, at least for a subset of the population, HRT does slightly increase the rate of venous thrombosis. If a patient comes in with a swollen leg, you may want to be aware of the potential, but HRT is very low risk," Dr. Pomeranz said.

A burgeoning area of research is whether topical estrogen can prevent skin aging. "There is some data to show that topical estrogen can help prevent skin aging, especially in post-menopausal women," Dr. Lo Sicco said. According to a Brief Report in JAAD, estradiol showed improvements in skin thickness and collagen, and estriol showed improvements in wrinkles, firmness, and hydration comparable to estradiol (doi: 10.1016/j.jaad.2025.08.050). 

Despite emerging evidence demonstrating some efficacy of topical estrogen on skin aging, the heterogeneity across these studies prevents broad conclusions from being drawn.

Researchers are also questioning whether hormone replacement therapy may have benefits for women with androgenetic alopecia, Dr. Lo Sicco said. "There aren't great studies yet, although clinical studies are currently underway."

Addressing sensitive topics

While dermatologists need to be gentle in their approach and attitude when addressing concerns in sensitive areas, they also should be matter of fact. "If we transmit a sense of embarrassment, then the patient will for sure be embarrassed," Dr. Pomeranz said. "It's also important to include patients in the exam process and explain each step as you go."

If a perimenopausal or post-menopausal patient is seen with extremely dry skin, Dr. Mauskar will use that as a lead-in to talk about the fact that dry skin is something that occurs everywhere on the body, including the vulvar region. "A lot of my patients will then let me know that they actually have really dry skin on the vulva or pain with sex or UTIs. If you open the door, they are so thankful to talk about it because they're nervous to bring it up."

Dr. Fotouhi stressed the importance of making genital exams a routine part of total body skin exams. "Our older post-menopausal patients are not getting regular pap smears anymore, so they're not getting regular gynecologic exams. We need to be the ones to look."

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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